Are you taking Ozempic, Wegovy, or other GLP-1 drug for weight loss? Here's what to know about the costs.
The state's second-largest insurer,
Whether GLP-1s are covered by insurance has huge implications nationally because the drugs, which were first approved to treat diabetes and later obesity, are also being studied for possible future treatment of a
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Here's what you should know about GLP-1s and how they're covered.
How much do GLP-1 drugs cost out of pocket?
The monthly price ranges from about $950 to $1,350, which adds up to more than $11,000 a year, at a minimum, before insurance and discounts.
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What are the brand names of GLP-1s?
Ozempic and Wegovy are two of the most well-known, due to extensive TV and marketing efforts. Others are Mounjaro, Saxenda, Trulicity, and Zepbound. GLP-1s are currently considered the world's hottest pharmaceutical products.
What does GLP-1 stand for?
Glucagon-like peptide. It is a hormone that plays a crucial role in regulating blood sugar, appetite, and digestion. It works primarily by stimulating insulin release, suppressing glucagon secretion, slowing gastric emptying, and increasing a feeling of fullness after eating.
Will other insurers follow Blue Cross's example by eliminating GLP-1 coverage?
Blue Cross is the dominant and most influential commercial health insurer in the state, with 3 million members. It's hard to imagine that Point32Health, the next largest commercial insurer with 1.5 million members, will continue to compete with Blue Cross at a significant financial disadvantage by covering expensive GLP-1s.
Will my employer help defray the cost if my GLP-1 coverage is ended?
There is a chance your employer will pick up at least some of the cost because doing so may help in employee recruitment and retention. But there is less flexibility for employers to do so if they have fewer than 100 employees and are 'fully insured,' as opposed to 'self-insured.' (Blue Cross and Point32Health offer both types of plans — more on this below.)
How does a fully insured plan work?
Smaller employers often avoid some of the risk of health insurance losses by contracting with an insurer such as Blue Cross to assume the risk of huge, unforeseen spikes in claims. (Those insurers also administer the plan.) When an insurer assumes the risk, it controls all aspects of the plan, including what drugs are — and are not — covered. In these circumstances, an employer has little discretion to add coverage of a drug such as GLP-1s. They must strictly adhere to the plan as designed by their insurer.
How does the size of the company affect insurance?
Because of the popularity of GLP-1s, Blue Cross is allowing more flexibility than usual for fully insured companies. Ordinarily, it would allow no variances in its plans. But for GLP-1s, it is allowing employers to continue to offer coverage of GLP-1s, so long as the companies agree to pay significant increases in premiums. But the option to continue coverage of GLP-1s is not available to companies of 100 or fewer employees because it is deemed too risky to the insurer.
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How does a self-insured plan work?
Self-insured employers are bigger companies with more resources that hire an insurer like Blue Cross to administer an insurance plan, but the employer assumes the risk of claims exceeding premiums. Because they pay their own claims, they are free to make changes in the plans they offer, including by adding coverage of GLP-1s (with an increase in premiums paid by employees).
How should I approach my employer about what drugs are covered in my insurance plan?
Insurance coverage is among the most important benefits offered by employers. (More than half of the state's residents are covered by an employer-sponsored health plan.) If you belong to a union, health insurance is a major component of contract negotiations. If you are choosing between job offers, the quality of the offered insurance may be a big factor in your decision. If GLP-1 coverage is important to you, make sure your views are communicated to your employer's decision makers.
Why would an employer opt to cover GLP-1s?
Besides recruitment and retention, a company may see GLP-1s as a path to lower its costs in the long run because weight loss generally improves health and could result in fewer and less expensive claims later. Some see GLP-1s as possibly significantly lowering overall future health costs.
How do I know if my employer is fully insured or self-insured?
Contact your company's HR department or check your health insurance paperwork. On the back of my insurance ID card it says my insurer 'administers claims payments and does not assume financial risk,' meaning my plan is self-insured.
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Are GLP-1s covered by Medicare?
Medicare does not cover GLP-1s prescribed solely for weight loss. But it does cover GLP-1s prescribed to reduce the risk of heart attack and stroke due to cardiovascular disease and obesity or being overweight.
President Trump upon taking office reversed the Biden administration's plan to expand Medicare coverage by including GLP-1s for weight loss.
Do Medicare supplemental plans cover GLP-1s?
They usually follow Medicare policies, so, generally, no, GLP-1s are not covered for weight loss.
Are GLP-1s covered by MassHealth?
MassHealth covers Zepbound for treatment for weight loss.
What's the future of the industry?
Drug companies are racing to produce GLP-1s in the form of a daily pill instead of requiring weekly injections, among other potential advances. They are also trying to reduce the side effects of these drugs.
Will the cost of GLP-1s eventually decline?
Yes, prices are expected to drop due to increased competition, generic versions, potential price negotiation in Medicare, and other factors. But increased demand could
Are 'compounded' versions of GLP-1s available?
Compounded drugs are made by pharmacies and are typically allowed by the Food and Drug Administration to augment supply when there's a shortage of the brand-name drug (though they are not FDA-approved). Such a shortage existed for some GPL-1s, but the FDA this month said the shortage has been resolved. The compounded drugs are
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